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REVIEW LECTURESfor LU 6

Basic Eye Exam

Common OPD Complaints

Common ER Cases

Pharmacology



INTRODUCTION

This is a REVIEW:

Repeat of some of your lectures last year. Aim: give you guidelines regarding what to

study; from now on you need to do a lot of

self study



The pace of the lecture will therefore be a

little faster than first-timers: about 40

sec/slide This entire lecture is in your handout

Just a guideline of topics to study

YOU MUST STUDY ON YOUR OWN



Ophtha is ³another world´

New terms, new skills, a lot of procedures The general rules of the Medical Profession hold

true

± TREAT THE PATIENT

± TAKE A CONCISE YET GOOOOOD HISTORY

± IF YOU ARE IN DOUBT: ASK! This is the importance

of the hierarchy in the Medical World

± THINK OF NOTHING- BUT TO GIVE PERFECT

SERVICE AND EVERYTHING, EVERYTHING ELSEWILL FOLLOW



BASIC EYE EXAM



Visual Acuity Testing

Check vision first before touching

patients¶ eyes or shining light ontopatients¶ eyes



Distance Visual Acuity

VA = 6/30 + 1

6/21 -2

If the patient is not

able to read all the

letters in a given line

± Record this as a (+) or

a (-) the number of

letters read or not read



Distance Visual Acuity

VA = 6/15 +3

6/12 - 2




If patient is unable to read the 6/60 line at

6 meters.

± Move the patient closer to a distance JUSTENOUGH for the patient to be able to read

JUST THE FIRST LINE

VA measurement = numerator is replaced by the

new distance where the patient was able to read

the first line e.g. 3/60




Finger Counting is never done at a

distance of 6 meters or more

If VA improves with PH, likely that poor vision is due to an EOR



Vision in Infants

When testing VA in infants

± Make sure that the only stimulus being used

is visual (no auditory stimuli e.g. bells)

± Observe if infant becomes irritable when one

eye is covered compared to the other

± Record VA as

(+) dazzle/ Centered, steady, maintained, able to fixate,

follows object



Near Vision

Near vision : NV

± If patient is able to read only figures larger

than those corresponding to the J16 line,

Near Vision is recorded as >J16



Gross Examination

Check eyelids and eyelash, check positionof lids

Check for proptosis, exophthalmos

Check corneal clarity and corneal lightreflex

Check sclera

Check pupil size and pupillary lightreaction

Check extraocular muscle movement



INTRAOCULAR PRESURE

Normal IOP 8-21 mmHg (Goldmannapplanation tonometer)

IOP difference greater than 2 mmHg inboth eyes: glaucoma screening isrecommended

Palpation tonometry: hypotonic, soft, firm

or hard Do not palpate if you suspect an open eye

injury !



FUNDUSCOPY

Check media

Check disc (difference of O.2 in CD ratio

between eyes is suspicious) Check retinal vessels

Check for presence of hemorrhages,

exudates or other lesions Check macular area and foveal reflex



Common OPDComplaints and Conditions



COMMON EYE COMPLAINTS

Decreased visual acuity

Photophobia

Colored Haloes

Red eye Painful eye

Protrusion

Squint

Inability to move eye

Exudation

Itching



Decreased Visual Acuity:

Error of Refraction

Distance vision ± All children by age 3 should have v.a. checked

± Errors of Refraction

Myopia Hyperopia

Near or Reading vision ± Errors of Refraction

Myopia

Hyperopia

Presbyopia



Decreased Visual Acuity: Cataracts

Note: check ROR, Dilated Pupil Exam



Decreased Visual Acuity: Corneal Leukoma



Decreased Visual Acuity: Glaucoma

Potentially blinding: check C/D ratio



Decreased VA: Retinal Diseases:

RRD with Proliferative

Vitreoretinopathy

Macular scar

Subretinal hge: AMD, trauma DM Retinopathy



Retinal Manifestation of Systemic Dse

Hypertensive Ret: AVcrossing changes

Branch Retinal Vein Occlusion Central Retinal Vein Occlusion

Macular edema / star



Decreased VA: r/o Systemic Disr/o Carotid/Cardiac Valve Plaques, Abnormal Lipid Profile, HPN, Drugs,

Contraception, Behcet¶s Dis

Cotton Wool Spot: (Large) / Branch

Retinal Arteriole Occlusion

Central Retinal Arteriole

Occlusion : CRAO

Branch Retinal Arteriole

Occlusion: BRAO

CRAO: Aratiles/Cherry Red

Spot



Decreased VA: Blinding Eye Diseases:

Potentially Life Threatening

Retinoblastoma

Note: mid dilated pupil: OS



Red Eye Differentials

Acute Angle Glaucoma

Hazy cornea: edema,

mid-dilated, shallow

anterior chamber

± Haloes

± Photophobia

± pain

Ciliary flush: dilated deep

conjunctival andepiscleral vessels around

limbus




Herpes Simplex Keratitis

Dendritic corneal ulcer



Red Eye Differentials: Conjunctivitis

Discharge: bacterial

± Purulent: creamy white

± Mucopurulent:

yellowish

Discharge: allergic ± Serous: white stringy



Bacterial Conjunctivitis

Discharge

± Purulent: creamy white

± Mucopurulent:

yellowish



Bacterial Conjunctivitis

Exudation: ³mattering´

± Conjunctival or eyelid

inflammation

± Not in acute glaucoma



Allergic Conjunctivitis

Hyperemia/dilation of

the conjunctival blood

vessels

Can have whitestringy discharge

Stringy discharge




Scleritis

Potentially serious

Inflammation: focal or

diffuse

Usually painful

Usually chronic

r/o collagen vascular

disease r/o rheumatoid

diseases




Subconjunctival Hemorrhage

blood between conjunctiva and sclera with

areas of intact white sclera




Blunt trauma

Hyphema vs Hypopyon




Pterygium

Triangular fold of vascular conjunctiva

creeping into cornea




Corneal Foreign Body

Surrounded by a rust ring and edema

Pain, foreign body sensation, tearing




Tarsal Conjunctival FB



Adnexal Eye Disease

Staph blepharitis: chronic

Inflamed eye lids

Swollen eye lids

Oily discharge

Eyelashes clump

together

Forms COLARETTE

around eyelash



Adnexal Eye Disease

Seborrheic Blepharitis

Dry, flaky lashes

Red lid margins



Adnexal Disease

External Hordeolum

Focal Staph infection

Red and painful

Acute swelling of

glands of zeiss and

moll also meibomian

glands

Points towards skin May be quite large



Adnexal Disease

Internal Hordeolum

Meibomian gland

Points towards

conjunctiva



ADNEXAL DISEASE:

Chalazion

Eyelids

± Chalazion: focal,chronic,granulomatousinfection of meibomiangland

Large non tender lidmass

May be chronic result of hordeolum

r/o sebaceous cellcarcinoma



Adnexal Eye Disease: Potentially

Life Threatening



ADNEXAL DISEASE

Lacrimal system

± Dacryocystitis

Results from

obstruction of

nasolacrimal duct

Pain, edema, erythema

over lacrimal sac

Discharge from puncta

is sign of infection

Ad l Di



Adnexal Disease

Nasolacrimal Duct Obstruction

Most common

congenital

abnormality

May be transient

May open in 3 weeks

Tears and mucus

may accumulatewhich may result into

dacryocystitis



Protrusions

Exophthalmos

± Forward protrusion of

globe

± Retraction of lids ± r/o leukemia in kids

Orbital mass

± Chemosis

± Hyperemia of conj

± Prolapse over lid

± Fixed eye: no EOM



Protrusion: Life Threatening

Tumors

± Melanoma

± Retinoblastoma



STRABISMUS

Phoria ± Latent tendency for misalignment

± May elicit problem by covering eyes alternately

TROPIA ± manifest when both eyes open

ESOphoria/tropia: eyes directed inwards

EXOphoria/tropia: eyes directed outwards

Vertical ± hyper and hypo



Strabismus

3rd Cranial Nerve Paresis

Ptotic lid

Failure to adduct

Failure to elevate

OS: Abnormal eye



Strabismus

6th Cranial Nerve Paresis

Failure to abduct

Eyes are straight inadduct gaze and

directly ahead

OS: Abnormal eye

OD: Abnormal eye: fails to abduct



COMMON ER CASES



TAKE VISUAL ACUITY

before examining the eye



Chemical burn:

can lead to blindness Differentiate between acid and alkali



ALKALI

Ammonia (NH2): fertilizers, cleaning

agents

Lye (NaOH): drain cleaners

Potassium hydroxide

Magnesium hydroxide: sparklers, flares,

firecrackers

Lime: plaster, cement, whitewash, mortar



CHEMICAL BURN:

TRUE OCULAR EMERGENCY

Alkali Alkali more serious than acid burn

The whiter the eye the poorer the prognosis



Acid

Sulfuric acid: car battery, industrial acid

Hydrochloric acid/muriatic acid: bathroom

cleanser, household acid

Nitrous acid

Hydrofluoric acid

Acetic acid (>10%)



Chemical Burn: Acid



Chemical Burn:

Initial ER Management Topical anesthetic

Copious irrigation with balanced saline solution

Check for retained foreign bodies, chemical

precipitates. Flip lids and swab fornices. Topical cycloplegics (atropine sulfate 1%), TID

Topical antibiotics (broad spectrum such asfluoroquinolones), q4 hours

Patch eye Prompt referral to ophthalmologist



Sudden, painless, profound

loss of vision!

Always consider vascular

etiologies.The other true eye emergency!



CRAO:

Central Retinal Arteriole Occlusion1. Afferent pupillary

defect is profound or

total

2. Extensive retinal edema

(pale retina)

3. Cherry-red/aratiles spot



CRAO: ER MANAGEMENT

Ocular massage (digital or 3-mirror lens): 10seconds ON, 5 seconds OFF

Induce hypercarbia: re-breath CO2

Sublingual isosorbide dinitrate 10 mg Lower eye pressure: acetazolamide 500 mg,

mannitol 20%, oral glycerol 50% (1 g/kg)

Anterior chamber paracentesis

IV streptokinase Prompt referral to ophthalmologist



Corneal Foreign Bodiesand

Abrasion



CORNEAL FB AND ABRASION

Common complaint at the ER

Usually work related (grinding,

hammering, chipping, etc.)

Accidental trauma (blast, insect, fingernail,

etc.)

Pain, tearing, redness, FB sensation,

photophobia, lid swelling



CORNEAL FB: METAL



CONJUNCTIVAL FB

This is how you flip upper lid. Foreign body has been removed.

CORNEAL FB & ABRASION



CORNEAL FB & ABRASION

ER MANAGEMENT Put topical anesthetic for exam purpose only

Examine under strong light and magnification

Remove FB with forceps or cotton swabs if

possible

May irrigate with sterile saline solution

Cover with broad spectrum topical antibiotics

(every 1 hour) Place semi-pressure eye patch

Prompt referral to ophthalmologist



Perforating Injuries of the Eye



PERFORATING INJURIES

One of the most common reason for admissionto eye ward at PGH

Majority of patients are male and children (30%)

are common Work or play related, assault and accidentaltrauma

Corneal, limbal, corneo-scleral, scleral etc.

Intraocular structures are usually involved Common cause of endophthalmitis and

blindness



Perforating Injuries

Sharp objects: wire, walis ting-ting, BBQ

stick, needles, knives, scissors etc.

Projectiles: metal fragment, nail, glass

fragment, dart etc.

Blasts: firecrackers explosion, gun blast,

dynamite, pillbox etc.



Intraocular FB: IOFB

Metallic Intraocular FB with vitreous hemorrhageNote: no protective eye goggles



Globe Perforating Injury

Do not extract: Will need xrays to determine extent of penetration



Corneal Perforating Injury: CPI

Prolapsed iris, peaked pupil,Peaked pupil, r/o incarcerted iris



Scleral Perforating Injury

P f ti I j



Perforating Injury:

ER Management Determine nature of trauma and extent of injury

Give anti-tetanus regimen

Start broad spectrum topical and systemic

antibiotic therapy

Eye shield

Avoid manipulation or pressure on the eye




Contusion Injuries of the Eye

(blunt trauma)

Closed Globe Injury

Open Globe Injury



Blunt Closed Globe Injury

Subconjunctival Hemorrhage Contusion Hematoma





r/o blunt closed injury r/o valsalva related r/o HPN

Subconjunctival Hemorrhage,



Subconjunctival Hemorrhage,

Contusion Hematoma:

ER Management Closed globe injury

Vision may be affected with ³Berlin¶s

Edema´ / ³Commotio Retinae´ Conservative management

Cold compress for the first 24 hours

Warm compress on succeeding days Resolution in 7 to 14 days



Blunt Globe Injury: Hyphemar/o Occult Ruptured (open) globe

Grade 3 Hyphema 8-Ball Hyphema



Hyphema: ER Management

High back rest

Limit activity

Eye shield Topical cycloplegic (atropine sulfate)

Monitor eye pressure




Ruptured Eyeball: Occult

HISTORY!, BOV, Severe conjunctival hyperemia, Eccentric pupil , Very

deep anterior chamber, hyphema, hypotonia



Ruptured Eyeball



Ruptured Eyeball

Blunt Globe Injury: Ruptured



Blunt Globe Injury: Ruptured

eyeball/ Open globe injury Determine nature of trauma and extent of

injury

Eye shield

Broad spectrum topical and systemic

antibiotics

Avoid any pressure on the eye




Urgent Red Eye Conditions

Acute red eye problems seen at

the emergency room

URGENT because it may be

possible to save vision

ACUTE ANGLE CLOSURE



ACUTE ANGLE CLOSURE

GLAUCOMA: AACG Severe eye pain and BOV

R edness, congestion,

injection

Headache, nausea, vomiting

mid-dilated, non-reactive

pupil

firm to hard eyeball



AACG

NORMAL EYECiliary conj congestion,Mid-dilated

pupil, corneal edema, pain,

haloes, photophobia



AACG: ER Management

Acetazolamide 500 mg, IV Mannitol 20%

(1 g/kg), oral glycerol 50% (1 g/kg)

Topical beta-blocker




Gonorrheal Conjunctivitis



Gonorrheal Conj: ER Mgt

Irrigate with sterile normal saline solution

Take precautionary measures to avoid spread

Ceftriaxzone 250 mg IM (neonate); 500 mg to 1

gm IM (adult); single dose Ciprofloxacin: 250 mg single dose; 100 mg BID

Azithromycin: 1 gm single dose




RETINOBLASTOMA

0-2 y.o. cat¶s eye reflex, squint, glaucoma, dilated pupil, extruding eyeball

REFER IMMEDIATELY TO A TERTIARY CENTER



OCULAR PHARMACOLOGY

The succeeding slides are all

included in the handouts. If

preferred, lecture of this section

may be deferred.



Drug Administration Routes

Topical: Anterior ± Drops, Suspensions, gels, ointments

± Low concentration in Posterior Chamber

Local Injection: Anterior & Posterior ± Injections, delivery devices

± Subconjunctival, Subtenons, Retrobulbar

± Intracameral, (anterior chamber) Intravitreal (vitreouscavity)

± Used for drugs with poor corneal penetration

± Higher risk and more apprehension

Systemic: Anterior & Posterior ± Oral, intravenous

± Has to penetrate blood ocular barrier

Commonly Used Ocular



Commonly Used Ocular

Therapeutic Drugs

Glaucoma or IOP lowering drugs

Antibiotics

Anti-inflammatory

Anti-allergy

Decongestants/Lubricants



IOP Lowering Drugs

Beta blockers

Cholinergic stimulators

Adrenergic stimulators Carbonic Anhydrase Inhibitors

Prostaglandin analogs

Hyperosmotics



Beta-Adrenergic Blockers

Block ß2 receptors in

ciliary processes

Reduce aqueous

secretion May protect optic

nerve

Side effects:

± Bradycardia

± asthma

Timolol

Betaxolol

Levobunolol

Metripranolol



Cholinergic Agonists

Increase outflow of

aqueous

Open trabecular

meshwork Side effects

± Pupil constriction

± Decreased vision

± Myopia

Pilocarpine

Carbachol



Adrenergic Agonists

Apraclonidine ± Decrease aqueous production

± Increase trabecular outflow

± Increase uveoscleral outflow

Brimonidine ± Decrease aqueous production

± No effect on tracular meshwork

± Increase uveoscleral outflow

Adrenergic Agonists:



Adrenergic Agonists:

Adverse Effects Apraclonidine

± Frequent ocular

allergy

± Arrythmias ± Restricted use

± Eye redness

± Hypotension

Brimonidine

± Headaches

± Fatigue

± Hypotension

C b i A h d I hibi



Carbonic Anhydrase Inhibitors

Block CAI enzyme

needed to produce

aqueous

SE: paresthesias,

tiredness, constipation or diarrhea

Renal stones, acidosis

Aplastic anemia

Stinging for drops

Oral

± Acetazolamide

± Dichlorphenamide

± Methazolamide Topical

± Dorzolamide

± Brinzolamide

P t l di A l



Prostaglandin Analogs

Novel drug

Increase uveoscleral

outflow

SE: hyperemia, Irishyperpigmentation,

ocular inflammation

No systemic effects

Have become #1 Rx

Additive with other Rx

Latanoprost

Travoprost

Bimatoprost

A ti i bi l



Antimicrobials

Antibacterials

Antifungals

Antivirals

Antiparasitics

A tib t i l



Antibacterials

Aminoglygosides ± Tobramycin

± Gentamycin

± Vancomycin

± Neomycin

Erythromycin

Polymyxin B

Chloramphenicol Sulfacetamide

Fusidic acid

Fluoroquinolones =

broad spectrum

± Ciprofloxacin

± Ofloxacin ± Levofloxacin

± Gatifloxacin

± Moxifloxacin

A ti i fl t St id



Anti-inflammatory: Steroids

Highly potent

Affect several areas

of inflammation

± Decreaseprostaglandins

± Decrease leucocyte

activity

± Preserve membranepermeability

± Anti-angiogenic

± Inhibit wound healing

Ocular SE

± Cataract

± IOP elevation

± Infections ± Delayed Wound

Healing

St id



Steroids

Topical

± Prednisolone acetate

± Dexamethasone

± Fluoromethalone ± Rimexalone

± Loteprednolone

Soft steroid, less risk of

increased IOP

Local Injection

± Anecortave Acetate

± Triamcinolone

± Methylprednisolone Systemic

± Prednisone

± Methylprednisolone

± Dexamethasone

NSAID



NSAID

Decrease

Prostaglandins

Decrease

leukotrienes Fewer ocular side

effects than steroids

Cause GI discomfort

Ocular preparation

± Diclofenac

± Ketorolac

± Indomethacin ± Ketotifen

A k l d t



Acknowledgement

Dr. Teresita Castillo

Dr. Alex Tan

Dr. Harvey Uy

Dr. Milagros Arroyo

Dr. Ma. Florentina Gomez



Thank you!

Good Luck!

STUDY!

Enjoy!

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